PART

IV

ELECT RO-S URGERY CHAPTER I SURGICAL USES OF ELECTRICITY

THE surgical uses of electricity, apart from its convenience for heating a cautery or lighting a lamp, depend upon its electrolytic and destructive power (vide p, I79), A continuous current is therefore a sz'ncqud non, It enables us to effect a local decomposition of the tissues exactly to the extent and 'within the limits desired; it introduces no poisonous caustic, it causes scarcely any after-pain, and the absorption of its products need not be feared, It is essentially docile and manageable, There are three chief methods of making use of it for these purposes: I. Both poles are introduced into the tumour by means of needles: this may be termed the bipolar method; it is speediest, but is more apt to leave scars, The resistance of the skin is entirely eliminated. This method is used in the electrolysis of ruevi, goitres, aneurisms, etc. 2, One pole only is introduced, and the other one is attached to a large external electrode (' unipolar' method), Progress is slower here, but if the negative pole be the external one, the risk of sloughing is reduced to a minimum. The resistance of the skin is partly eliminated This method is adopted for some aneurisms, removal of hairs, etc.

224

'\IA:"T.4.L

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}lEDlcAL

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3· Both poles are in close apposition, but do not penetrate the skin or mucous membranes, This method is used by Apostoli for uterine fibroids ; and in modified forms by others for strictures. General Requisites for Electro-Surgery. These are an ordinary gah-anic battery of Leclanche, or other cells (large size preferable-for a portable battery, the Hellesen or other dry elements); a collector and current reverser : a milliampere meter reading to ISO m.a, for ordinary 'work, and to 300 m.a. for A..postoli's method; a rheostat, rheophores, a large indifferent electrode, and others of special shape for Apostoli's method, as well as for treatment of the urethra, lachrymal duct, Eustachian

FIG,

I IS. -ELECTROLYSIS

:'\EUJLE.

tube, and the oesophagns : needles of various sizes of platinum, gold, and steel (their stems should be insulated by vulcanite sheaths to avoid injury to the skin, though painting with ordinary shellac will be sufficient, provided it be renewed after every application) The needles should be provided with arrangements permittmg of their being attached together to the same rheophore (Fig. TI8). The ncedle attached to the positive pole ber ornes decomposed by the current, but platinum and gold are less affected by this oxidation process than are other metals, and they are therefore usually chosen for this purpose, unless the caustic and hrernostatic effects of the salts of iron are desired. It is difficult also to giye a platinum needle anything like a stable fine point, and its introduction is therefore more difficult and painful than is that of a steel one.

ELECTRO-SeEGERY

225

Removal of Superfluous

Hairs.

This is an operation that is easily and rapidly performed. Four to six cells of an ordinary gah-anic battery (5 m.a.) are required; an electrolysis epilation-needle with a make and break key on the handle (Fig. JIg), and a pair of epilation forceps. The patient should be comfortably seated, or reclining in a good light. Place a medium-sized well-moistened pad electrode attached to the positive pole over the sternum, and secure the kathode to the electrolysis needle. Grasping the hair in the epilation forceps, press the needle-point down for about } inch into the hair follicle beside the hair. :'IIake the current for a few seconds, a few bubbles

of gas will escape, and the hair can be lightly drawn out. pain is felt during the passage of the current, but an anresthetic is never required. About ten to fifteen hairs can be removed at a sitting. i\ 20 per cent. ointment of cocaine can be applied afterwards to soothe any irritation. ,1" small red spot marks the site of each operation for a few days, but no scar results. The Rontgen ra:ys may also be made use of to remove the finer hairs.

A stinging

Trichiasis.
Ingrowing same way. eyelashes can be successfully removed in the

Small Tumours

and Warts,

The small fleshy and pendulous tumours can be readily and almost painlessly removed by introducing into them a

15

226

A .i\L"..:\UALOF PRACnC\L

J.IEDICAL ELECTRICITY

needle connected with either pole. The positive pole is slower in action, but less likely to cause a scar. A current of 3-7 m.a. may be passed for two or three minutes. If the negative pole be used, the flesh}.'mass will swell up, and bubbles of gas will rise round the needle. X 0 haste in repeating the operation should be displayed, for the tumour will continue to shrink for some little time. Warts can also be similarly electrolysed and destroyed, but the operation is a painful one, and they usnally return quickly. They may be treated by the Rontgen rays.
Nzevi.

Not much, unfortunately, that is worth the doing can be done by electrolysis for cutaneous nrevi and port-wine stains (t1ide Rontgen rays), and other nrevi on the scalp or on covered parts of the body are more rapidly dealt with by the ligature or knife; but for subcutaneous nzevi on the face, or in complicating situations, electrolysis is the best treatment, because it causes the minimum amount of scarring, and is most easily directed and localized. The old method was to pass one needle only into the nrevus and to connect the other pole to a large indifferent electrode; the modern method is to pass into it several needles attached respectively to both poles; or if only 1\'1'0 needles be inserted, to move one of them about. The operation is in this way very much shortened. Requisites. An ordinary galvanic battery of from ten to forty' cells (if possible of large size), Leclanche or Hel1esen; if Stoehrer's battery, or if Bunsen cells be used, a smaller number will suffice. A milliampere meter, rheophores, and needles; the latter may be of platinum, steel, or gold; they should be insulated, except close to the point, so as to avoid destroying the skin. Coxeter makes a convenient form of needle-holder for fastening the needles to. Dr. Jones has devised a bipolar fork electrode (Fig. 120) so arranged that several needles alternately positive and

ELECTRO-SVRGERY

ZZ7

negative can be screwed into it. By this means the needles can be kept at equal distances from each other, and cannot come into contact, however moved about. Two assistants are required, the one to administer an anaesthetic, and the other to watch the milliampere meter and manipulate the cell-collector. All being in readiness, the needles, if separate, are introduced one by one with a slight twisting motion, and the

FIG.

rzo.·-LEWIS

Jmms'

AYD OTHER EPILATION

NEEDL]!;S.

current turned on, and gradually increased to from 60)0 100 m.a. The assistant should watch the galvanometer carefully to prevent any short-circuiting from the needles accidentally meeting in the nsevus ; this would be indicated by a sudden great increase in the current-strength, and is remedied by slightly displacing the various needles until the short circuit be broken. As the current passes, the tissues round the needles change in appearance and texture; bubbles of gas are formed round the negative needles, and the tissues soften and swell; a hardening and contraction occur round the

15~z

228

:\lAXl'AL

OF PR.~CTICAL

MEDICAL

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positive needles. The skin around the naevus becomes As the tissues are seen and felt beneath the finger to change, the needles should be one at a time withdrawn, and reinserted in other parts, so as to distribute the decomposing and cauterizing effect. When every part of the tumour has been attacked, and a doughy induration produced, the current should be gradually reduced to zero, and the needles slowly withdrawn; the negative needles will be found to be quite loose, and the positive somewhat firmly fixed. If any difficulty be met with in withdrawing the latter, some hsernorrhage may follow; it is better, therefore, in such cases, when the current-strength has been sufficiently reduced, to temporarily reverse its direction; this will immediately loosen them. The time the operation will last depends upon the size of the nrevus, and upon the current-strength and number of needles employed: most cases can be completed within fifteen minutes. Dr. John Duncan prefers to use two needles only; he keeps the positive one fairly steady, and he moves the negative one about in all directions, so as to cauterize enry part of the tumour. In certain cases, where the smallest possible amount of scarring is desirable, it may be well to introduce the positive needle only, the negative pole being attached to a pad on the sternum; this considerably prolongs the trca tmen t required. The operation may require repetition, but plenty of time should be allowed for the na,TUS to undergo the retrogressive changes set up. The after-treatment is. simple; the punctures may be painted "with collodion, and the part kept at rest with a pad of absorbent cotton, and a bandage.
hvperrernic.

Goitres. The vascular and soft varieties are those best adapted for treatment by electrolysis; but all kinds, even the i:ystic and exophthalmic, may be thus treated and often

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229

benefited (J. Duncan). They should be treated Eke nrevi, but with only t\VO needles introduced; the latter should be of platinum or steel, and should be plunged in at the equator, so as to avoid the thyroid vessels. The positive needle may be kept fairly steady, but"the negative one should be moved about. Large active cells are best=Bunsen's, Stochrer's, or Hellesen's; the current-strength. may go up to IQO m.a. Dr. John Duncan has by this method had excellent results. Dr. Kuttner, of Berlin, prefers to introduce the negative needle only, because its destructive action is more intense and complete, and the necrosed products are more rapidly absorbed; the absorption of the hardened and acidly cauterized products of the POSiti\T pole is much slower. He places one or two negative needles in the tumour, a large positive electrode over the sternum, and passes a current of 60-70 m.a. for ten or twelve minutes. The operation is repeated every two or three days. Of nine cases so treated, two were completely cured, and five greatly' ameliorated. Cases in which laryngeal pressure is prominent are quickly relieved.

Cirsoid Aneurisms.
These should be treated in the same "vay. They are very amenable to electrolysis, and can always be cured by it. Two Or three seances may be required.

Aneurism by Anastomosis
is not so amenable to electrolysis. size, it may be successfully treated. ment is the same as for goitres'. If, however, of small The method of treat-

Aneurisms.
~Iany attempts have been made to utilize electrolysis in aneurisms, especially in those thoracic ones that are not amenable to ordinary surgical treatment; it has been hoped that the clotting which occurs around the poles might serve as a nucleus for further coagulation and deposits

230

JHANUAL OF PR.\CTlCAl

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of fibrin, and that the aneurism cavitv might in this way become partially fiJled up. Such attempts have not met with much success. Ciniselli treated thirty-eight cases by the introduction of needles connected with both poles, and by reversing the direction of the current eyery five minutes; of these twenty-seven were ameliorated, but none cured. Dr. John Duncan attained the most favourable results in popliteal, femoral, and axillary aneurisms; sixteen out of twenty-nine of these were cured, only six out of thirtyseven in the aortic variety, Dr. Petit, in the ' Dictionnaire Encyclopedique,' gives the following statistics: Of II4 cases of aneurism of the aorta treated by electrolysis, 68 were improved (i.e., 59 per cent.), In aneurisms of the extremities complete cure is the rule. Various methods of utilizing electrolysis have been adopted. In the unipolar method one pole only was introduced, and the other was connected 'with an indifferent pad placed in the vicinity. The difficult question was which pole to introduce. The positive pole gave the best and firmest clot, but, being difficult to withdraw, sometimes led to hsernorrhage, or even to rupture of the vessel. The negative pole gave a large, unsubstantial and frothy clot, largely made up of hydrogen bubbles, which was not only of little value in setting up a stable coagulation, but was thought to be dangerous from the risk of emboli. Then, when both needles were introduced, the greatest precautions were taken to keep the exposed part of the needles well in the middle of the blood stream, and not to cauterize the wall of the sac, and this because there is risk of ;(a) Hsemorrhage from the needle punctures. (b) Inflammation of the wall of the sac. Dr. John Duncan has quite recently been treating cases on an opposite plan. Believing that these precautions have been rather overdone, and that good rather than harm might result from a somewhat freer use of the

ELECTRO-S

URG ER Y

.needles, and being of opinion that in our fears of hremorrhage and suppuration we were not taking all the advantage we might of the current, he now makes a practice of from time to time gently moving the positive needle about in the sac, so as to bring its point into contact with, and to slightly cauterize, various parts of the sac wall. Roughenings arc produced by these means, which form further nuclei for the deposits of fibrin. Indications for Electrolysis. Electrolysis is indicated chiefly in those thoracic and subclavian aneurisms in which medical treatment has failed, and in which the only other alternatives are the distal ligature, amputation at the shoulder-joint, or the introduction of coagulants; even though there be danger of external hremorrhage, the operation is still indicated, for electrolysis checks the hremorrhage. Method of Procedure. A battery of twelve or more large Leclanches, eight to ten Hellesens or Stoehrers, or five to eight Bunscns, a milliampere meter, rheostat, rheophores, and two long needles carefully insulated in their stems, are required. The patient should be kept absolutely quiet, both during, and for some time after, the operation, Both needles should be inserted (more than two needles add complexity and the risk of aftcr-hremorrhage without corresponding advantage ; the unipolar method docs little good unless yery strong currents are used). \Vhen the needles are in situ, the current should be gradually turned on, the patient being carefully watched for any signs of faintness; if all go "Yell, the strength of the current may be brought up to from about twenty to thirty milliamperes as the limit. The positive needle may now be gently moved so as to touch and slightly cauterize the sac wall in one or two places. After a seance of from ten to twenty minutes, the current may be gradually cut off, and the needles then withdrawn ; if the positive needle

232

}IAXT.TAL OF

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sticks, the current can now be temporarily reversed to disengage it; except for this, it should throughout the operation be steadily maintained in the one direction. Dangers of the Operation.

Hremorrhage, inflammation, and embolism. Hremorrhage from the point of puncture can be avoided bv passing the needle through the thickest part of the wall of the sac, by haying its stem well insulated by vulcanite, and by cutting off the current before withdrawing the needles, so as to avoid cauterizing the track of the wound. Inflammation of the sac wall and suppuration of the track of the needle are rarer occurrences ; the latter may lead to a fatal hsernorrhagc, as in a case reported by Dr. Henry Simpson. Rigid antisepsis and complete rest after the operation arc the best preventives, Embolism apparently need not be feared; no case of it, to the author's knowledge, has eyer been reported.

Results.
If the operation be successful, the tumour hardens and shrinks, and may occasionally be wholly cured; further, any tendency to external haemorrhage is temporarily arrested. Commonly, there is some flattening down of the tumour, with relief from the pulsation and pain. After a few- days' rest the operation may be repeated. The resistance of the blood in an aneurism has been stated by Bartholow to be about eight ohms; m:'l reasons for doubting this have already been mentioned. Dr. John Duncan, using six Bunsen cells, has rarely obtained a current of 70 Ill.a.; supposing, however, that roo m.a. were obtained, then, as by Ohm's law (disregarding polarization, which, at any rate, cannot be ,-cry effective in a moving stream), R=~. Then
2

volts x 6 I2 -~- =- -=I20 '! ampere 'r

ohms,

ELECTRO-SCRGERY

which is approximately the resistance the current is encountering, and allowing twenty ohms for the resistance of the galvanometer, etc., this 'would leave about IOO ohms as the resistance in the aneurism; but, of course, very much will depend upon the distance the needles are from each other, the number of needles inserted, the amount of the stem uninsulated, etc. Dr. John Duncan has been kind enough to write to me the following letter in regard to the results of his twentysix years' experience in electrolysis: , In aneurism, within the last two years, I have made a new departure, which, I think, promises well. I had found that, while electrolysis might be used with complete success in small external aneurism, and in attacking the secondary sacs of aortic aneurism, I did not obtain with it those occasional brilliant cures which had, in the hands of others, been observed. In taking away the risks of hcemorrhage and inflammation of the sac wail, which had formerly prevailed, I had also greatly diminished the curative power of the agent. In short, I came to see that the cure had been in most cases due to the very cauterization of the sac which had been thought to be so dangerous. I had no deaths, but none of the old sudden cures; I had trusted for cure to the coagulation, the effect of which is slight, and had e1iminated cauterization. 'I determined, therefore, about three years ago, to gently cauterize with the positive electrode the inner wall of the sac, and I have now had two very satisfactory results by this method, which I hope to publish when they are completed. '1 L~~:t:\~b:f..-- ., ~,;~ , In cirsoid aneurism, which I define as a tumour composed solely of enlarged arteries (most common on the temporal), further experience has confirmed what I long ago stated, that no other method of treatment approaches electrolysis in safety and certainty. I have cured every case I ha ve seen. ~~~i.j ,It is different with angiomata, in which metamorphosed capillaries, veins, and arteries a1'eall involved. In some of

>'-

234 A

_jlA:-<UAL

OF

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them I have failed to bring about a cure, generally because of their size or situation, although in the majority I have been perfectly successful. c In the subcutaneous and mixed forms of nrevus, when they arc situated on parts of the body where a scar is to be avoided, electrolysis is the safest and most certain of 811 our remedies; but in port~wine stain it is useless, unless you are prepared to leave a scar, and in those portions of the body on which a scar is of no moment, excision is much more rapid. 'In aneurism I include in the circuit a galvanometer and rheostat, and use not more than 20 to 25 rn.a. In the angiomata generally these precautions are less necessary. Anything from 20 to 80 m.a, will do, and you judge by the effect on the tumour in doughy induration and swelling, and especially avoid producing any alteration of colour in the skin.'

CHAPTER II STRICTURES
ELECTROLYSIS has been successfully used for stricture of the urethra, rectum, Eustachian tube, cesophagus and lachrymal duct. That stricture of most kinds can be safely and pleasantly removed by the local cauterizing and decomposing action of electrolysis cannot be doubted; the main reason why it is not more generally adopted is the comparative slowness and expense of the method. The misuse of electrolysis by those inexperienced in electrical apparatus, the strong currents employed, with their sometimes serious results, and the rash advocacy of enthusiasts have also created a prejudice against it. When a urethra (an be dilated by readier and simpler means in much less time, and without the special knowledge or apparatus that electrolysis requires, few surgeons will be found to prefer the latter. It has, however, certain advantages, It is, when properly administered, safer, because there is no bruising or sudden stretching of the tissues; it is less painful-no an-esthetic is ever required or should be given; the patient will rarely complain of anything but a slight tingling or pricking; there is no hasmorrhage, and there is, for all these reasons, less shock or chance of subsequent rise of temperature. It has been stated that antiseptics are not required, because the process itself is aseptic; but this can scarcely be the case, for we saw (p. r8z) that the negative pole, the one always used in urethral electrolysis,

236 A

l'IIAxCAL

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1IFDICAL

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has no antiseptic action at all. cautions are as much required operation on the urethra.

Rigorous antiseptic prein this as in anv other

Stricture of the Urethra. Requisites: A battery of ten Leclanches or other cells, a milliampere meter, rheophorcs, an indifferent pad electrode, and a case of different-sized urethral bougie electrodes (Fig. I2I). The latter should be of gum elastic, with olivary-shaped nickel-plated ends; as the negative pole is the only one used internally, platinum is not necessary. A wire passing

FIG.

12T.-C-"SE

OF URETHRAL

ELECTRODES.

along, and insulated by the stem of the electrode, connects the exposed olivary-shaped end with a terminal bindingscrew. Mode of Procedure. With the patient lyil1g down with the indifferent pad, which should be attached to the positive pole of the battery, beneath him, the size or the stricture, and the distance it is from the meatus, should be ascertained by means of an ordinary bougie, proper antiseptic precautions being taken. An electrode, one or two sizes larger than the calibre of the stricture, should be chosen, and the distance it will have to pass to reach the stricture marked

ELECTIW-SU,GERY

237

upon its stem. It should now be gently passed along the urethra until it rests by its weight merely against the stricture, and should then be connected by means of the binding-screw and rheophore with the negative pole of the battery. By using the cell-collector the current is now turned gradually all, and brought up to between three and five milliamperes; <1. greater strength is not desirable, and would cause the patient pain; the current should be maintained for about fifteen minutes, unless the electrode be previously felt to pass through the obstruction. The current being first turned off, the electrode may be withdrawn. \Vhcther the stricture has been passed through or not, the symptoms due to it "will be relieved, and the patient will be able to pass water more easily. A slight slough may follow the withdrawal of the electrode, or may appear at a later period. The operation may be repeated with a larger bougie in about a fortnight's time. The negative pole is selected for the reasons already mentioned under the treatment of goitre, viz., that it softens and dissolves away the tissues in a manner that allows of their ready absorption; the positive pole hardens and dries them. The operation is, with these precautions, and the weak current recommended, an easy and simple one, but as several seances are usually required, and as they should not be repeated oftener than about once a fortnight or so, a prolonged treatment is necessary. Results. From the observation of numerous cases, the late Dr. Steavenson believed that electrolysis was one of the most efficient and satisfactory modes of treating stricture of the urethra; there was no comparison, in his opinion, between the treatment of stricture of the urethra by ordinary methods and its treatment by electrolysis. }lr. Bruce Clarke allows three weeks to intervene between the sittings. If at the first sitting the stricture took a :;:0. 4, in a fortnight or three weeks a :-.r 0. 8 or 9 would pass; in such a case treatment would begin again with a Xo. 10 bougie

238

IYL-\:\UAL OF PRACTICAL

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electrode. Quoting from a table of fifty cases, he showed that twenty-three were known to be well after periods varying from one and a half to three years, and in two cases no relapse had taken place after four years, whilst only nine were known to have required subsequent treatrnent. At the meeting of the J,Iedical Society, at which Mr. Bruce Clarke's paper "vas discussed, other surgeons expressed themselves as opposed to the treatment. }Ir. Hurry Fenwick remarked that he had treated twenty picked cases of stricture of the urethra by electrolysis, and that they were all the worse for the treatment; two of them had developed troublesome traumatic strictures, and the method was also one not without danger, for the electrode had been known to perforate into the rectum, to produce troublesome hcemorrhage, and to lead to a fatal issue at least in one case. The fact that the electrode had in one case perforated into the rectum clearly shows that the urethral stricture had not been treated in a proper manner. \\'ith a current of 5 m.a. it would take days, unless manual force were exerted, to bore a hole through the intervening 'tissues. 1\' a one should attempt even such a simple electro-surgical operation as this without a proper knowledge of his apparatus, and without a galYanometer in the circuit; nor should he entertain the idea that the best mode of procedure is straightway cotlie que cottte to electrolyse a sufficiently large hole through the stricture. Dr. Robert Kewman, who introduced the method described, recommends the following precautions: The use of very mild galvanic currents, just perceptible to the patient, and from three to five minutes in duration; the use of the negative pole held loosely against the obstruction without pressure or force; long intervals (from two to four weeks) between the applications. Dr. Fort, of Paris, treats strictures by linear electrolysis (Lancet, August 23, r890)- He has operated on 700 strictures of the urethra without a single fatal result by this method, He uses the eleciroleur, an instrument in-

ELECTRO-SURGERY

239

vented by him, which, by means of a linear exposure of metal, ploughs a narrow furrow through the obstruction; the operation when properly done is innocuous, without pain and blood, and no bougie is afterwards required. The conclusions of the author are as follows: Linear electrolysis may be used for all kinds of stricture. Owing to the simplicity and harmlessness of the operation, and owing to the greater infrequency of relapses by this method than by others, the author considers that linear electrolysis should be preferred to urethrotomy, and ought to constitute the operation par excellence in the treatment of stricture of the urethra, Chronic Inflammation of the Urethra. A gleet may often be benefited and caused to heal by judicious electrolytic cauterization. The position of the tender, unhealed, and discharging surface should be localized, and the exposed head of the bougie electrode used for stricture brought against it. The latter is attached to the negative pole, and a pad connected with the positive pole is placed over the lumbar enlargement; a current of about 4 m.a. is passed for about four minutes, and the electrode gently moved up and down so as to attack the whole of the diseased area. The seances may be repeated about every ten days. The Prostate. Hypertrophy of the prostate may be treated by electrolysis or galvano-cautery. (Tripier has used faradization.) The electrolytic treatment resembles that of a urethral stricture. A special prostatic electrode, insulated except on the convex margin of its point, should be passed along the urethra until the exposed surface rests against the enlarged Jobe (guided to the position if necessary bv the finger per the rectum). It should be attached t; the negative pole, and a current of about 5 m.a, passed for about ten to twenty minutes. The operation may be repeated in about a fortnight. The result is to cauterize and dissolve away portions of

240

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the obstructing tissue. It is needless to add that this is a far safer operation than that with the galyano-cautery. }Iorotti recommends Bottini's thermo-galvanic cautery (British Medical Journal, jlay 23, I89I). An instrument is used which combines both an incisor knife, a cautery of small platinum plates, and tubes for the circulation of water: a cautery battery of accumulators or bichrornates is required. The operation consists in passing the instrument with the patient in the lithotrity position. \'i"hen the point is in the bladder, it is turned downwards and gently drawn forwards so as to cause the beak to hitch against the prostate, and bring the cautery in contact with the part on which it is desired to act. If there is any doubt, the exact position of the instrument should be ascertained with the finger in the rectum. The current is now turned on, and the point pressed against the hypertrophied tissue, while a stream of cold water is made to circulate through the instrument. By gently elevating the handle of the instrument the point is made to burn its way slowly through the prostate. \Yhen the sound of burning is distinctly heard, the point should be gently moved backwards and forwards, until the projecting lobe is completely divided. \Yhen it is judged that sufficient tissue has been destroyed, the current should be shut off, but the instrument should be left in situ for two or three minutes, so as to allow it to become cool before it is withdrawn. The knife should next be restored to its sheath, and the instrument pushed into the bladder, so as to make sure that it is not caught anywhere, and then withdrawn. For the after-treatment, if the patient cannot pass water in the natural way, ::;elaton's soft catheter should be used. The eschar usually separates from the tenth to the fifteenth day. Professor Bottini has operated in this manner in fiftyseven cases with two deaths, in thirty-two cases with a perfect cure, in eleven with improvement, and in twelve with no result.

ELECTRO-SURGERY

24I

The method is not altogether free from danger unless the greatest care is used, and it should be reserved for cases in which strangury is persistent. Dr. Newman also prefers the galvano-cautery. Dr. Casper, of Berlin, employs electrolysis by galvano'puncture. A needle electrode insulated except at its point, and connected with the negative pole, is pushed into the prostate from the rectum; after a few minutes it is partly withdrawn and passed into another part of the gland, and after a second interval into another part. A current of from IO to 25 m.a. is employed and maintained altogether for about fifteen minutes. If the cnrrent does not exceed I5 m.a. the operation is not a painful one. Frequent repetitions (about every ten days) are required to insure a complete cure. This occurred in two out of four cases so treated, but in a third a recto-vesical fistula was produced. The strictest antiseptic precautions are required. By this operation holes are bored into the hypertrophied tissue, and their walls then cauterized and disintegrated; the result is to set up so many foci of necrosed matter, by means of which, through the ordinary processes of absorption, cicatrization, and contraction, the gland becomes much reduced in size. The Rectum. Non-malignant strictures, especially if of syphilitic origin, may be treated successfully by electrolysis. A suitably-shaped bougie electrode, insulated except at its olivary-shaped head, one or two sizes larger than the calibre of the stricture will admit, should be chosen. It should be attached to the negative pole, and the method is the same as that for urethral stricture, except that the results are more rapidly attained, because stronger currents (10-20 m.a.) and more frequent repetitions (every four days) can be borne. The current may be kept up for twenty minutes, and no ana.sthetic is required. Dr. R. )J ewman, whose method is the one described, after an r6

242

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experience of fourteen cases, has come to the following conclusions: In the treatment of strictures of the rectum electrolysis is not a panacea. On the contrary, it may be unsuccessful, especially in carcinomatous strictures. Electrolysis will often succeed in those rectal strictures in which all other methods have failed. A certain proportion of cases can be better cured by electrolysis, and with less fear of a relapse, than by other methods. The fibroid strictures due to old inflammations offer the best chances of success. Hsernorrhoids have been treated by the introduction of

a
E~).{X

FIG.

122.-EcSTACHIAN

C.'cTHETER.

a needle attached to the positive pole; this coagulates and dries up their contents. The electrolytic treatment does not offer any particular advantages. The Eustachian Tube. Successful attempts have been made to relieve strictures of the Eustachian tube by electrolysis. An electrode made to slide in the ordinary Eustachian, catheter, Fig. I22, and attached to the negative pole, is used; the catheter having been introduced in the ordinary \vay, the electrode is gently pushed along the Eustachian tube until the obstruction is met with ; the current is then turned gradually on (the pad attached to the positive pole may be placed on the nape of the neck or sternum), and brought up to about 3 m.a.

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The patient will not experience any pain, but will hear a peculiar bubbling sound. The current should not be maintained for more than two or three minutes, and the electrode may, even before this time, have overcome the obstruction. Mr. Cumberbatch and the late Dr. Steavenson performed this operation a large number of times without any unpleasant experiences, or more than a little temporary discomfort to the patients. ::VIr. Cumberbatch, the aural surgeon to St. Bartholomew's, has written as follows as regards the operation: 'Our experience is at present too limited to be able to say what cases of chronic catarrh of the middle ear are most likely to be benefited by this new method of treatment. That strictures of the Eustachian tube, which do not yield to the ordinary methods, can be cured by the use of the electric bougie we have proved. In many cases of chronic catarrh with obstruction of the tube, there is no actual ankylosis of the ossicular joints, and in such a case restoring the patency of the tube, and thus relieving the pressure on the membrana tympani and the chain of ossicles, must act beneficially on the hearing, etc. In conclusion, I may add that if after three or four trials a patient experiences no benefit, the probability is that further treatment by this method will be useless.' Lachrymal Obstruction. :\1r. Jessop and the late Dr. Steavenson, in the British ]1.1dical J ournal for December 24, r887, recount ten cases e treated electrolytically. The canaliculi are readily enlarged by a suitable probe electrode; for the nasal duct the probe should be insulated except near its point. In both cases the probe should be attached to the negative pole, and weak currents of from 2 to 4 rn.a, used. The (Esophagus. It has been suggested that strictures of the oesophagus should be treated electrolytically. The same general method would be employed.

r6-2

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Growths and polypi in the nasal fossreand naso-pharynx have been treated both by electrolysis and the galyanocautery. Kuttner treated a case of hypertrophied tonsils by electrolysis. The left tonsil was cured after three, and the right one after five, galvano-punctures.

CHAPTER III DISEASES OF WOMEN Fibroid Tumours. ApOSTOL[ states that chemical galvano-cauterization (electrolysis) can produce three principal results: I. Arrest of pain. z. Arrest of hsemorrhage. 3. Some diminution in the size of the tumour, together with relief from the pressure symptoms. Further, as opposed to the previous attempts to make use of electricity in uterine tumours,he points out that his method isI. Precise, because he always measures the currentstrength by a galvanometer. 2. Energetic, because he makes use of currents of great strength, 50 to 250 m.a, For all that, it is 3. Tolerable, by reason of his large moist day abdominal electrode. 4- Better localized, by direct application of the active electrode to the uterus, or to the substance of the tumour. 5. Thoroughly under control, because he both uses the unipolar method, and by means of proper apparatus can apply currents of any desired strength and duration. 6. More scientifically exact, from the due appreciation of the topical effects of the two poles. Two main effects are claimed:
(a) Polar; (b) Interpolar. • (a) The polar or tangible effect is a chemical cautcriza-

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tion more or less severe, and different in character according to the pole used. (b) The interpolar effect is that which results from the circulation of the current from one pole to the other. This action sets up a subsequent process of disintegration of the morbid products through which it is made to pass. (The interpolar action is somewhat obscure, Vide TIl. 'Neiss' experiments. p. 179.) The positive pole is a hzemostatic more or less rapid in its action, and either direct or immediate, or secondary and remote. By it 'we can arrest haemorrhage, either instantly, if the cavity of the uterus be of normal dimensions, if the action be relatively intense, and the h.ernorrhage not excessive; or more deliberately and gradually, after several applications, by the formation of contractile cicatrices. The 'positive' pole will therefore be the medicament, par excellence, in cases of "hsemorrhagic fibroids. With the negative pole ,'Ie produce a state of temporary congestion without direct hrernostatic effect. The interstitial circulation of the uterus will be hurried on, and a retrogression of the non-hemorrhagic fibroids is the consequence either of this state of congestion or of the supplementary artificial and salutary haemorrhages which take place. The negative pole will therefore be found to render invaluable benefit in those cases of fibroids accompanied with amenorrhcea and dysmenorrhcea, which are only too often the despair of both patients and doctors. The' positive' pole is the express remedy for the cases attended with' haemorrhage ' ; the' negative' pole when they are not' ha::rnorrhagic.' As a supplement to these rules, viz., the positive pole intra-uterine for the restraining of hcemorrhage, the negative pole intra-uterine for tumours without hsemorrhage, comes the second indication for 'galvano-punctures.' These latter assume daily, as my experience increases, a more and more preponderating importance in my estimation.
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The indications for galvano-puncture are twofold: first, as a matter of necessity in consequence of uterine atresia, or where there is such displacement of the organ as to prevent any introduction of a sound; second, by preference when we see that we can advantageously combine punctures with intra-uterine cauterization, so as to expedite and make sure of the effects that, with the cauterization only, we should tardily, or, perhaps, imperfectly, realize. vVe must therefore undertake the galvanopunctures alone whenever the case will fairly admit of them, or use them in other cases as adjuncts to the intrauterine cauterization previously tried. \Vhat are the anatomical and clinical results of these procedures ? As regards the' material' changes, we may affirm that every fibroid submitted to this treatment, sometimes after so short a time as one month, but certainly when the treatment is fully carried out, will undergo a manifest reduction appreciable by the touch and demonstrable by internal measurement. The further diminution of the tumour, which continues for some months, varying in amount from a fifth to one-half of the original volume, is generally associated with a coincident and equal accumulation of subcutaneous adipose tissue on the abdominal walls, The liberation of the tumour from its local attachments takes place simultaneously with its decrease of bulk; the tumour, which at the commencement of the treatment was immovable, can progressivdy be made more and more to change its position, as the absorption of the enveloping tissues deposited round it advances. The tumour also not only contracts in itself, but exhibits a tendency to separate itself from the uterus, to become more distinctly subperitoneal, to detach its mass, as it were, from its setting in the uterine wall, and to remodel itself into a pedunculated form. The' clinical' results are not less striking. \Ve may generalize the extent and importance of these results by

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saying that ninety-five times out of one hundred they comprise the suppression of all the miseries constituting the fibroidal symptomatology, which may thus be categorically enumerated. Haemorrhages, the troubles of menstruation, dysmenorrhoea, amenorrhcea, nervous disturbances, the direct pain in the growth itself, and from mechanical pressure, and the harassing series of reflex actions. In a word, the assertion may be safely advanced that though our therapeutical resources only carry us so far as the sensible reduction of fibroid tumours, and not to their total absorption, we rna:.', with regard to the symptoms, certainly anticipate a complete removal, and the establishment of a state of health equivalent to a true resurrection. I am justified in saying that most women . who have persisted in the necessary treatment, not only were cured but remain well. 'Finally, I may lay down the following proposition: No operator should admit the failure of intra-uterine galvano-cauterization before having had recourse to galvano-punctures, which he must enforce either with or without ansesthetics, , In the five years ending July, 1887, I have made 5,20I applications of the continuous gah'anic currents on 403. patients for various gyna:cological conditions; of these I have only to deplore the loss of two, and of these two deaths I take upon myself the entire responsibility. My method was not in fault; I only 'was to blame. Once there was a fatal error of diagnosis, a suppurating ovarian cyst being unrecognised, death resulting from peritonitis; in the second case, a gah'ano-puncture was made too deeply. The consequence was intra-peritoneal gangrene, for which the abdomen was not opened. In addition, I have to confess to having either excited or aggraYatedin the course of five years ten peri-uterine phlegmonous inflammations. These must be attributed to blunders in the carrying out of the treatment. During the five years there were 278 patients suffering from fibroid tumours, or hypertrophy of the uterus; all these have not been cured,

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because many did not persevere with the treatment; but I can affirm that, when there has been no negligence, and my advice has been fully acted on, ninety-five times out of one hundred permanent benefit has been acknowledged' (vide paper read by Dr. Apostoli at the British Medical Association, 1887). So much for Apostoli's own account of his method and results down to 1887. When the author was in Paris, in April, 1892, he attended Dr. Apostoli's cliniques, and observed that he "vas making much use of the alternating sinusoidal currents of M, d'Arsonval, also of electropuncture, and apparently not so much of the simple continuous current. Dr. Apostoli had at that time not formed a definite opinion as to the efficacy of the sinusoidal currents, but the patients 'whom the author questioned all acknowledged that they had derived benefit from them; the pain and leucorrhrea were lessened, and they slept and felt better. Dr. R. Milne Murray, in the Ed£nbl£rgh i'v[edicat ] oarnai, January, 1902, makes the following remarks upon the present position of the Apostoli treatment: , This is not the occasion to discuss at any length the ultimate value of Apostoli's contributions to gymecological therapeutics, but I venture to assert my firm belief that, in spite of its inconvenience, its tedium, and its uncertainties, Apostoli's method would have been in general vogue to-day had it not been for the extraordinary success which, in the hands of experts, has attended the surgical treatment by hysterectomy of fibroid tumours. It is a much more expeditious procedure to extirpate the uterus and tumour by a single operation than to cure it symptomatically by electrical applications during two or three months-always supposing the patient does not die in the former case. But, on the other hand, there are multitudes of women suffering from the presence of a fibroid tumour who shrink from the suggestion of the knife, and refuse to submit to any surgical procedure. That a very large number of these rna:')'be symptomatically cured by
L

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Apostoli's method does not admit of a doubt, and I do not despair of a time coming when a woman may have some choice between a proposal for a hysterectomy and the somewhat melancholy consolation to be derived from the assurance that very few women die from a fibroid.'

CHAPTER IV Requisites for the Apostoli Treatment. A BATTERY of forty to sixty Leclanche, or persulphate of mercury, or thirty to fifty Hellesen cells, of large size, because the body resistance in the Apostoli treatment is much diminished (perhaps 100 to 400 ohms). A cell-collector capable of throwing ODe additional cell at a time into the. circuit. A good rheostat: Dr. Milne Murray's double tube liquid one, or an ordinary single tube Iiquid one containing water to which a few drops of milk have been added (vide , Rheostats '). The single tube sulphate of copper solution rheostat scarcely presents sufficient resistance. A milliampere meter reading to 250 or 300 m.a. A large twelve by ten inch abdominal electrode. Apostoli recommends potter's clay. This is mixed up "lith water until a plastic, adhesive mass is formed, which is spread out in a layer about half an inch thick on a piece of tarlatan: Upon this is placed a metal plate provided with a binding screw, and the muslin is folded over so as to enclose the clay. This electrode has the disadvantages of being troublesome to prepare, ami of being cold to the patient. Dr. Franklin Martin, of Chicago, makes use of a nickel-plated concave plate covered with a membrane, and having an insulated rim to prevent contact between the metal surface and the skin. On the plate is a nozzle through which warm water can be poured, and which passes into the space between the membrane and the concavity of the plate. This is easily prepared, is agree-

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able to the patient, and is deem. Dr. Milne Murray recommends a simple twelve-inch pad of amadou thoroughly moistened with dilute salt solution; all this is placed a

S
FIG. 123.-A
CTERIXE::

SOl·1,m ELECTRODE.

FIG.

J24.-DR.

?dlum

ivIl'RRAY'"

ELECTRODE.

leaden coil like Leiter's, which both keeps it in position and conducts the current to all parts of the amadou. The flexible pillow carbon electrode, already mentioned, will

FIG. 125.-ApoSTOLI'S

ELECTRODES.

also serve the purpose; it is cleanly, easily managed, and clings closely to the body. A uterine sound electrode. The exposed end should be about half an inch to one inch in length, and made of

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platinum, gold, or carbon; the stem may be made of copper, carefully insulated by vulcanite, Apostoli now uses gas carbon electrodes; a metallic stem, insulated by caoutchouc, bears a screw at one extremity, to which rods of gas carbon, all one inch in length, but of different diameters, can be attached. The caoutchouc covering is marked with grooves at regular distances of one inch (Fig. 123). For galva no-puncture a sharp-pointed steel trocar sliding

FIG.

u6.-ARRANGE.IIENT

OF .-\Pl'-'l.RATU5 TREAnmNT.

FOR

THE ApOSTOL!

in an insulating sheath of celluloid .. If the positive pole be used to puncture with, the needle shou.d be of gold
(Fig, 125).

Preparation of the Apparatus. Connect the rheophore coming from the positive pole of the battery to one of the binding screws of the rheostat, and a wire passing to the galvanometer to the other (Fig. 126); let them be on a firm table; then attach a long wire intended to reach the uterine sound to the other terminal of the galvanometer. Let the rheostat be screwed out to its full distance. Attach the other rheophore to the

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negative pole of the battery. Tum on all the cells, and plunge the ends of both terminal wires into a vessel of water, taking great care not to allow them to touch. Gas should now be pretty freely gh'en off, and in much larger quantity from the negative terminal. This decides two questions-whether all the cells are properly connected and in working order, and which of the two wires is the negative one. If the poles of the battery are not marked, and there should be any further hesitation as to the quality of the wires, a piece of litmus paper may be moistened, and the two wires made to touch it; the positive wire will tum the part it touches red. The collector may now be brought back to zero. Disinfect the uterine sound electrode by passing its point through a flame, and then by placing it in a carbolic solution. Preparation of the Patient. The patient should remove her corset and loosen her skirts; she should be assured that she will feel no pain or shock at all provided she will keep perfectly still, and that you will leave off at any moment should she desire it, but that she must not on any account move or rise until yon giyc her Ieave. The intermenstrual period should, if possible, be chosen ; but if serious bleeding be going on, the operation may be done at any time. The Operation. Let the patient have an antiseptic douche. Place her in the ordinary gymecological position on her left side on a firm couch; let the nurse kneel at the opposite side. Pass the sound, and then ask the patient to turn slowly on to her back, while the nurse holds the sound firmly. Bare the abdomen, examine it for any spot or abrasion, and cover them, if found, with collodion and a few threads of cotton-wool, or with oil-silk. Sponge the abdomen with warm salt solution, and apply the warm moist flannel or pillow electrode; connect this electrode to the wire coming from the negative pole. Connect the wire from the

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galvanometer to the extremity of the sound. (The wire should be well insulated, and great care taken to prevent any exposed metallic part from coming into contact with the patient's thighs.) Now gradually turn on the cells by the collector until the current has risen to about thirty rnilliarnperes ; pause a little, and then screw down the rheostat, until the patient begins to complain. If the patient will allow' it, the current may be taken up to about 200 m.a. ; it should be maintained for about eight minutes, and then gradually cut ofL A second antiseptic douche should follow, and the patient should then rest for a couple of hours or longer. The very greatest care must be taken to see that no interruption of the current occurs during the seance; the binding-screws should be firmly screwed down on the wires, and a commutator on the battery avoided. The operation may be repeated once or twice a week, according to the condition of the patient, and the treatment should be persevered in until some twenty seances have been held. Dur:ing acute inflammations, especially if suppurative, this treatment is contra-indicated. The opera tion described (positive pole intra-uterine] is of most use in hremorrhagic fibroids, particularly if submucous or interstitial; if there be no hsemorrhage, it will probably be useless. Apostoli recommends the negative pole intra-uterine, or galvano-puncture for non-heernorrhagic fibroids; the latter will be the most effectual. Galvano-Puncture, The preliminaries are the same as for the previous operation. Chloroform is usually required. The steel trocar should be attached as a rule to the negative pole; but it may at the first seance be attached to the positive (less painful and destructive). Apostoli gives the following principal rules (Bigelow, , Gymecological Electro-therapeutics ') :

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, Strict antiseptics both before and after. Use a very fine steel trocar. 'Kever make a puncture in the anterior cul-de-sac. Confine it to a lateral or to the posterior cul-de-sac. 'Choose for the seat of puncture the most prominent point in the tumour found in the vagina, making it project more, if necessary, by directing an assistant to press it downwards from above the pubes. }lake the punctures without a speculum. First fix in the celluloid sheath the needle to the depth of the puncture to be made; then, having ascertained with the index finger that there is no arterial pulsation, allow it to rest upon the point to be pierced; then slide underneath this finger the celluloid sheath which is to carry the trocar until its open mouth shall rest upon the exact spot; then push the trocar home, its penetrating! depth having been properly adjusted. Make without exception only superficial punctures, not more than half a centimetre, or at most one centimetre deep, so as not to cause any central gangrene, and to admit of an incessant antiseptic treatment. , The strength of the current may be at first from twenty to fifty milliamperes, Second or third punctures may be made if desired. , Let the patient have an antiseptic douche afterwards, and then pack the vagina with iodoform ganze. The patient should remain for one or two days in bed after a seance. 'Repeat the operation only at the end of a week or fortnight, so as to avoid accumulations of fcetid matter; suspend the seances temporarily if there are any threatenings of fever.' That this is a much more serious operation than the former is evident. The bladder and rectum have been perforated, permanent fistulse set up, large bloodvessels wounded; but the great risk is, of course, that of sepsis. Apostoli also recommends galvano-pundure for cases of salpingo-ovaritis in order to concentrate the effect of the current on the diseased tissue, and for fluctuating tumours of various sorts which demand rapid evacuation.

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Endometritis. Cases of chronic endometritis may be treated by intrauterine applications of the negative pole (the positive if there be much hremorrhage). The procedure is much the same as that for fibroids, but the electrode should be moved about in the uterus in such a way as to leave no part of the diseased mucous membrane uncauterized. The strength of current may be from roo to 200 m.a., and the duration about five minutes. Half a dozen seances may be sufficient to effect a marked improvement. Dr. Playfair remarks: 'In the treatment of certain morbid conditions of the endometrium, especially chronic endometritis, etc., I have found the application of the negative current through the insulated intra-uterine sound produce far more uniformly good effects than any other form of intra-uterine medication with which I am acquainted. I am quite satisfied that there is nothing to compare with it in these very troublesome cases, many of which had lasted for years, and resisted every kind of treatment previously used.' Obstructive Dysrnenorrhcea, if due to stenosis of the cervix, may be relieved by enlarging the os with the negative pole; the operation resembles that for other strictures, but stronger currents -15 to 30 m.a.-can be used. Membranous Dysrnenorrhrea can be treated in the same way as endometritis. Menorrhagia and Metrorrhagia. Ha:morrhages of all kinds, whether dependent upon fibroid tumours, subinvolution, endometritis, retained abortions, etc., may all be relieved by the use of the positive pole. Malignant Tumours. Electrolysis has been proposed and tried for these. It effects some local destruction, and sometimes relieves the

I7

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pain. Except when other more radical surgical operations are inadmissible, it is not to be recommended. (Consult Beard and Rockwell. : Electrolysis of the Base,' p. 695 of ' Medical and Surgical Uses of Electricity.') Extra-uterine Fcetation. Electrolysis has been used to kill the fcetus and check the growth of the tumour. (Vide report of several successful cases, Beard and Rockwell, p. 630.) Faradism has also been used. The method is unreliable and dangerous; the latter for two reasons: inflammatory and septic processes may follow the electrolysis. (Vide Dr. Percy Boulton's paper in British Medical jOl£rnal, April, 1887,) The treatment, moreover, by taking up valuable time and postponing more effectual measures, is endangering the patient's life.